Provider Demographics
NPI:1891891073
Name:ELLER, DEEANNA LEE (ROH)
Entity Type:Individual
Prefix:MRS
First Name:DEEANNA
Middle Name:LEE
Last Name:ELLER
Suffix:
Gender:F
Credentials:ROH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BEAUDRY BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208
Mailing Address - Country:US
Mailing Address - Phone:818-957-5654
Mailing Address - Fax:
Practice Address - Street 1:1134 N BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202
Practice Address - Country:US
Practice Address - Phone:818-246-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10263124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist